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FOR OFFICE USE: � � FOR OFFICE USE: <br /> APPLICATION FC%R SANITATION PERMI.,­ "1h <br /> , <br /> ---- - ------------------------- Permit No:- -*-•-------------- <br /> (Complete in Triplicate) <br /> ------------------------------------------------------- - <br /> - Date Issued___ ."_ _____------- <br /> ----------------------------------________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and,install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I <br /> !OB ADDRESS/LOCATION--- - --- - -�------- ------ -------------------------------- ----- -- ------.CENSPhoneAC <br /> Owners Name_._____-011 _____ <br /> ------- ------------- --- <br /> �._ ---- � L---------------ZiA-- �� �1 <br /> Address � �-��--- --.�-z.'/�.r�N�Lr L ----------------------- - ------..CitY------------- <br /> Contractor's Name----- ---- 4�-�� --- ----•---------=---------------------License # Phone__4 <br /> I� <br /> Installation will serve: Residence ❑. Apartment House❑ ;Commercial ❑ Trailer Court ❑ a <br /> g , <br /> Motel Other---'------=---------- - - - ---=--------- - ���� <br /> Number of living units:,_____ ___Number of bedrooms:__ _Garba e Grinder Size_.--- -_____ h_____-/--✓________________� <br /> +� Water Supply: Public System and name-------- ----- - - --------------------------------------L -. eat _ ._--Sand---Loam-------- -Cla Loam---- --------------Private sE <br /> Chgaracter of soil to a depth of 3 feet: Sand [J,.---Silt y ❑ Cay❑ ,VA ❑ .,,'Sandy ❑ y ❑� —`1 <br /> Hardpan-' ... __ Adobe. . __ Fill Material.- . I#. es;• Pe__ <br /> P ❑ a� - Y tY <br /> (Plot plan, showing size of lot, location of system in relation to:wells,buildings,.etc..must-be,placed-bn raverses)de.) <br /> NEW INSTALLATION: (No septic tank-,or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE-TREATMENT I';] SEPTIC TANK [ ] Sze________ __________________________ _____-___Liquid Depth. <br /> -- <br /> Capacity :Type =-=----`- -- _Material-------------- No: Compartmeits _ <br /> ,. <br /> Distance.to nearest: Well-------- -_ __ ___________Foundation 1_______________ Prop <br /> - Line <br /> -______________ <br /> ach line Lngth.. - <br /> LEACHING LINE No. of Lines------- ---- --------------Length o = t <br /> 'D' Box--------_---Type Filter Material :1_ _,-Depth Filter Material________________ ___ _ : "------------------------------- <br /> Distance, <br /> ______ __ __Distance to nearest: Well-----------------------------Founclation---- ______ ______________Property Line---------------------------------- <br /> SEEPAGE <br /> __ __________SEEPAGE PIT ;[. ] DTP ---- _-_- _ __Diameter- Number ----------------------------- Rock Filled Yes❑ No- <br /> . <br /> Waer Table :RockI-- ----- <br /> Di-starice:to'nearest: Well--------------`_y----------------------__-,."Foundation------------------ -- <br /> -------.Prop.Line------- -- --- -- - <br /> REPAIR/ADDITION (Prev.-Sanitation Permit# ;,_____.Date______ __ _ - ___._: ] l <br /> oo <br /> Septic Tank(Specify Requirements)---__.1 �______�' -- _ <br /> Disposal Field (Specify Re.quirements)---------------------- ------------------=------ ------ ------=------------------------------------------------ -------------------------------- -- <br /> ---- ---------------------------=---------------------------------------------------------------------------------- <br /> -----'-------------------------------------------------------- ----------------------- --- -- - <br /> ---------------------- <br /> + (Draw existing and required addition.on reverse side) ? s <br /> hereby certify.that.] have prepared.this application and that-the work will be done-in accordance with San Joaquin County <br /> Ordinances,. State Laws, and Ryles and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> f signature certifies the following: , <br /> : "1 certify that in'the performance of:the work for wh' h this permit is issued, '] shall not employ any person in such mariner as <br /> to become sub' t .to Wpf. man's p ation. I of California." E. <br /> Signed- i r ... --..Owner <br /> 1{`rr BY---------------------------------------------------- -=--:------.------------------------- _ --- <br /> -Title------------------------- <br /> (If other than owner) " <br /> 'FOR-DEPARTMENT USE ONLY <br /> r it N <br /> APPLICATION ACCEPTED BY = - ------------------------------------DATEi r ------- <br /> : DIVISION OF LAND NUMBER.- ------------------------------------------DATE.--------------'---- - <br /> ADDITIONAL COMMENTS------------------------ --= -----------------------•---------- -----------------------------=--------------------------- --- <br /> L <br /> --------------- ---------------------------- ------------I=----------------------------------------------------------------------------------------------------------------------;---------------------- <br /> ----- ----------------------------------------------------------------------------------------------------- -------------------- ------ -. --- ---------- ---- -------------------------------- <br /> -----=------ <br /> ` I <br /> Final Inspection-by: -------=-=----------- � � - Date�� <br /> - - --- --- - ----- -------------------------- - - -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M <br />